压疮评估与治疗的进展资料.ppt

压疮评估与治疗的进展;;A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear. A number of contributing or confounding factors are also associated with pressure ulcers; the significance of these factors is yet to be elucidated. 皮肤损伤 通常发生在骨隆突处 是压力和/或剪力、摩擦力对皮下组织损伤的结果。 ;;Pressure Ulcers May Not be Preventable有些压疮是难以避免的;Primary risk factors for development of pressure ulcers are形成压疮的原发危险因素;Pressure Ulcer Classifications 分级 ;Stage 2:Partial Thickness Skin Loss Partial thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater二期压疮; Stage 3:Full Thickness Skin Loss Full thickness skin loss involving damage to, or necrosis of, subcutaneous tissue that may extend down to, but not through fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue 三期压疮 ; Stage 4:Full Thickness Tissue Loss Full thickness skin loss with extensive destruction, tissue necrosis or damage to muscle, bone, or supporting structures (e.g., tendon, joint capsule). Undermining and sinus tracts also may be associated四期压疮;Unstageable: Depth Unknown Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore Category/Stage, cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as ‘the body’s natural (biological) cover’ and should not be removed. ; Suspected Deep Tissue Injury: Depth Unknown Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by t